CLAS A-Z: A Practical Guide for Implementing the National ... · When the National Standards for...

CLAS A-Z: A Practical Guide for Implementing the National Standards for Culturally and Linguistically Appropriate Services

(CLAS) in Health Care

Introduction, Purpose, and Suggestions for Using the Guide

The Purpose of this Guide: When the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care were published for public comment in the Federal Register on December 22, 2000, health care organizations began to contact OMH and private consultants seeking assistance in implementing culturally and linguistically competent health care services that would meet the new national standards. OMH has supported the preparation of this step-by-step guide to assist health care organizations to create a health care environment that would meet the very real needs and expectations of an increasingly diverse patient/consumer population. Suzanne Salimbene, Ph.D., President of Inter-Face International, a company that works to bridge language and cultural gaps in health care, was awarded a contract to develop the guide.

Availability of Professional Assistance: Users of this guide will be able to express their concerns and ask questions about the implementation of the checklists and instructions. At the end of the guide, there is a user evaluation. The author will answer all questions to the best of her ability, responding personally to the particular institution that has submitted the question. User comments, suggestions and criticisms will be carefully considered in the future editing of each module. All comments are welcomed in an effort to develop a flexible, easy-to-use and practical guide to cultural competence in health care institutions.

How to make most effective use of the guide:

• Designate a single person or committee to be ultimately responsible for institution-wide implementation.

• Read the short introduction to each section of the guide to gain an overview of the purpose and the contents of the checklists or forms.

• Circulate the checklists or forms to the particular person or group most likely to have access to the information requested. Ask that party to choose a responsible person for the completion of the form(s) and/or questionnaire(s) and to establish a deadline for returning the completed form(s).

• When all of the checklists, questionnaires and forms have been returned, read the part of the guide which describes how to best interpret or utilize the information received.

• Choose someone to be responsible for the actual implementation of the goals of that module (i.e. the drafting and tracking of a long-term plan).

• One may wish to form a committee made up of all the individuals responsible for the implementation of each set of goals. This way the committee may meet

© Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved i

regularly to assess the progress in establishing a culturally and linguistically competent organization.

• The above committee should be responsible for compiling the annual self-assessment described in Section #9 of the guide.

© Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved ii

Guide Format and Table of Contents

Format

This guide is designed to be practical and easy to use. It contains a minimum of cursive text. The majority of the guide is in the form of downloadable and reproducible "checklists", forms, and syllabi that healthcare organizations can use or adapt to their specific needs. Although these checklists are designed to be used in sequence in their entirety, each section is "self-contained." Institutions not wishing to implement the entire program according to the guide can use individual "steps" or "checklists." The guide presents a suggested order of implementation of the CLAS Standards. Following the section number and the title is the number of the CLAS Standard to which it refers.

Table of Contents 10. A rationale for decision makers: reasons why we must strive towards cultural

and linguistic competency Full buy-in from the organization's senior decision-makers is essential to the success of any cultural and linguistic competency initiative. This rationale for implementing the CLAS Standards is directed to the top leadership. The rationale section also stresses the fact that this initiative can be accomplished within an institution's existing budget.

List of reproducible forms and instructions:

a. An important message to health care decision makers: the compelling rationale for cultural & linguistic competency.

Further Reading 2. Guide to conducting and interpreting a cultural self-audit (CLAS Standard #9)

This section briefly explains the need for a cultural and linguistic self-audit prior to embarking upon a cultural competency initiative. It provides downloadable "checklists" or forms to carry out this audit and explains how to analyze the results to determine "the most needy" divisions of the organization - i.e. where the organization needs to concentrate its initiative. List of reproducible forms and instructions:

j. Guide to conducting and interpreting the institutional audit

k. Checklist #1: Present and future patient demographics (CLAS Standard #11)

l. Checklist #2: Present staff demographics (CLAS Standard # 2)

m. Checklist #3: Assessment by leadership

n. Checklist #4: Evaluation of current actions to enhance cultural & linguistic competence

© Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved iii

o. Checklist #5: Patient/community access to culturally and linguistically

appropriate care

p. Checklist #6: Community involvement, input and support (CLAS Standard #12)

Further Reading

3. Guide to devising a workable strategic plan (CLAS Standard #8). This section is designed to guide the institution to the creation and implementation of a written strategic plan for initiating and fostering cultural and linguistic competency throughout the organization. The plan helps each organization define long-term and short-term goals and develop specific plans to achieve each goal. The strategic plan covers a 5-year period and suggests some mechanisms for measuring success and reporting upon progress on a yearly basis. It also guides institutions in re-defining and extending goals once the 5-year period has been completed.


a. Checklist #1: Setting and articulating cultural competence goals to fit into the organizational mission statement, operating principles and service focus

b. Checklist #2: Developing a 5-year plan

j. Checklist #3: Developing an accountability hierarchy for CLAS and cultural competence leadership throughout the organization

10. Guide to insuring that patients/consumers receive effective, understandable and respectful care that is provided in a manner compatible with their cultural health beliefs and preferred language (CLAS Standard #1). "This standard constitutes the fundamental requirement on which all activities specified in the other CLAS Standards are based," as stated in the published version of the CLAS Standards. The term "understandable" refers not only to language, but also to culture. This standard assures care in a language (whether in the preferred language of the patient/client or in English that can be easily understood) and in concepts that are understandable from his or her cultural or religious framework.


a. Checklist #1: Improving the "effectiveness" of care

b. Checklist #2: Improving the "understandability" of care and services

j. Checklist #3: Improving the "respectfulness" of care

k. Checklist #4: Developing customer satisfaction questionnaires to assist in evaluating the "effectiveness," "understandability" and "respectfulness" of care and services

l. Checklist #5: Interpreting the results 11. Guide to promoting diversity throughout the organization (CLAS Standard #2)

© Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved iv

Staff diversity is not, in itself, a guarantee of an organization's ability to provide its patients/clients with culturally or linguistically appropriate care and services. It does, however, improve the comfort level of culturally diverse patients. It demonstrates that the organization recognizes and values the members of the patient's ethnic group. According to CLAS Standard #2, diversity is measured not merely by numbers but by an organization's ability to hire and retain a staff that reflects the demographics of the service area. Staff diversity needs to be encouraged and supported throughout all ranks of the organization. While at this time it may not be possible to achieve exact parity between patients and staff at all job levels, a clear demonstration of good faith efforts to develop concise strategies for working toward this goal will be recognized as meeting this standard. (Note: The majority of this section will be the concern and responsibility of the human resources department.) List of reproducible forms and instructions:

a. Checklist #1: Utilizing patient and staff demographics to evaluate the

organization's "Diversity Profile"

b. Checklist #2: Evaluating the organization's efforts to attract and retain minority staff members (Note: Sources for advertising openings to minority applicants for managerial and medical positions)

j. Checklist #3: Evaluating job advancement options and opportunities for minority groups

k. Checklist #4: Developing a plan to improve minority representation throughout the organization

Further Reading

12. Guide to providing the language access services that have been mandated by Title VI of the Civil Rights Act of 1964 (CLAS Standards #4, 5 ,6 & 7) The specific services relating to language access for limited English speaking patients are already required of all organizations receiving federal funds. CLAS Standards #4, 5, 6 & 7, which relate to these provisions, are categorized as mandates rather than recommendations. Good faith efforts to work toward total language access represent an acceptable step in the right direction if they are accompanied by a strategic plan for broadening this access to less populous groups. Multilingual signs, culturally-appropriate translated written documents, and trained medical interpreters in the preferred languages of at least 3 of its primary service population groups may be considered an adequate "starting point." The reproducible checklists aid in the implementation of language services for these primary groups.


a. Checklist #1: Informing patients of their right to language assistance

b. Checklist #2: Establishing adequate signage in other languages

© Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved v

c. Checklist #3: Developing appropriately translated patient information and patient education materials for all patients in the service area

d. Checklist #4: Creating an efficient, cost-effective system for medical

interpretation

Further Reading

13. Guide to on-going staff training throughout the organization (CLAS Standard #3) This section will assist in the evaluation of current training in cultural and linguistic competence and the development of a plan to ensure that this training becomes an on-going process at the institution. It presents a list of core topics that should be included in training. This list has been subdivided into three levels of competence according to job performance requirements and the amount of contact staff members are expected to have with diverse patients and colleagues.


j. Checklist #1: Evaluating current training in cultural and linguistic competence

k. Checklist #2: Planning for on-going training throughout the organization

l. Checklist #3: The three levels of cultural and linguistic competence

Further Reading 14. Guide to the development of positive, participatory and collaborative

partnerships with community organizations and support groups of culturally diverse populations in the service area (CLAS Standard #12) These alliances will ensure that each group's health care needs and concerns are met in a culturally appropriate manner.


a. Checklist #1: Strengthening ties with communities through contacts with grass root organizations

Further Reading 9. Guide to annual self-assessment and evaluation

This final step in an organization's journey toward cultural and linguistic competence is linked to both the creation of a workable strategic plan and constant revisiting of the institutional audit. These checklists should be repeated each year as a means of evaluating the institution's progress in meeting its goals. It is recommended all yearly self-assessments be saved. They will provide a comprehensive picture of the institution's journey toward cultural and linguistic competence. List of reproducible forms and instructions:

a. Checklist #1: Annual institutional self-audit

b. Checklist #2: Review of employee and patient grievances and patient satisfaction

© Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved vi

c. Checklist #3: Examining and re-evaluating short and long-term goals (Note: Refer to the completed forms of Section #3 of the guide to complete this checklist).

Assessment and evaluation of the effectiveness of the guide

© Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved vii

Section #1, An Important Message to Health Care Decision Makers:

The Compelling Rationale for Cultural & Linguistic Competency

Changing Health Care Population and Staff Cultural and linguistic competence has become a necessity for the survival of any healthcare organization. The mainstream White patient and staff populations may soon become minorities. The U.S. Census Bureau predicts that within the next 50 years, nearly one half (48%) of the nation’s population will be from cultures other than White, non-Hispanic. Many from these population groups hold health beliefs extremely different from the Northern European beliefs upon which our U.S. health system was founded. This increase will impact both patient and staff demographics. The world views, communication styles, work habits and ethics of culturally diverse staff members will be different from that of primarily White employees. To achieve both customer and staff satisfaction and loyalty, each organization will need to broaden its cultural and linguistic competency.

Culture, Patient Compliance and Health Outcomes Satisfaction and loyalty contribute to an organization’s economic well being. Successful outcomes to medical treatment are strongly influenced by linguistic and cultural access to care. Compliance with treatment, as well as the retention of culturally diverse patients and staff, will impact risk management, the number and outcome of medical malpractice suits and employee grievances. An adaptation of services that are more appropriate to culturally and linguistically diverse patient/client groups will lower the chances of bad outcomes due to miscommunication or misuse of medications and medical advice.

Culture, Access to Care and Health Care Regulating Bodies Cultural and linguistic competence is now recognized as a major component in the accessibility of health care. Most recently (August, 2001) the Surgeon General’s report: Mental Heath: Culture, Race, Ethnicity unequivocally stated the need for mental healthcare providers to gain a better understanding of the culture of their patients and the impact of cultural beliefs and practices on a patient’s access to and response to care. Appropriate provisions to the language needs of patients were mandated by Title VI of the Civil Rights Act of 1964. All health care organizations that receive federal funds are also required to demonstrate their ability to provide both culturally and linguistically appropriate care and services. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) mentions the need for culturally appropriate care and services eighty seven times in each of its accreditation manuals. The Department of Health and Human Services Office of Minority Health (DHHS-OMH) spent two years in the preparation of the Culturally and Linguistically Appropriate Services (CLAS) Standards. This composite of existing mandates and recommendations regarding the specific needs and objectives of cultural competence in health care, draws together all that has been done, thus far, in achieving these goals. The CLAS Standards are summarized in Appendix I of this section of the guide. These steps by regulatory bodies indicate the direction in which health care is moving. They demonstrate a strong determination on the part of monitoring bodies, to assure access to health care which is linguistically and culturally appropriate to an increasingly diverse patient population.

© Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved 1

A Brief Summary of the Culture, Language and Health Care Connection Culture plays an extremely important role in health care. It determines how one defines health, wellness, illness, youth, and old age. People learn their health/illness and illness prevention beliefs and practices from the culture to which they belong. That culture determines whether or not preventative measures such as periodic check-ups, vaccinations, mammograms, and Pap tests, are taken. It impacts the decision to accept or reject medical advice and/or treatment. Culture also determines how patients expect to be treated by each member of the healthcare organization with whom they interact. Because none of us are immune to culture, it also influences the expectations of caregivers regarding how patients should behave toward one another, their caregivers, and the healthcare system as an institution. See Appendix II of this section for examples.

The Who, What, When and How in Creating & Maintaining a Culturally Competent Health Care Institution What behaviors, practices, and policies are required to provide culturally and linguistically competent care to an increasingly complex and diverse group of patients? More important, how are the required knowledge, strategies and skills acquired and maintained? Cultural and linguistic competence should become an intrinsic part of each institution's mission. Treatment plans will not be followed or valued by the culturally diverse consumer unless they are both culturally and linguistically appropriate. Each organization needs to become culturally competent at all levels and maintain this standard on a daily basis.

Implementation of CLAS Implementation of CLAS will include on-going intervention. Cultural and linguistic competency requires changes in the basic assumptions and communication styles that each member of the organization has developed over the course of his/her personal and working lifetime. Changes include:

• System-wide interventions to heighten cultural and linguistic awareness and Sensitivity.

• The acquisition of new skills, strategies, and knowledge. • Consistent support and reinforcement from senior leaders. • Information seminars about the rules and taboos of population groups in the

service area. • Easy-to-access cultural references for medical staff. • Staff training on how to effectively utilize medical interpreters.

How to Use this Guide to Enhance the Cultural Competency of an Organization

• Designate a high ranking administrator with decision making power as Director of Diversity (This person may wish to work alone or form a Diversity Council or Committee).

• The Director of Diversity should oversee the implementation of this step-by-step guide. In some cases, he or she should adapt the suggested steps to meet the structure of the organization. This person must have the authority to delegate the


completion of each of the 9 sections to the appropriate person or department in the organization. The checklists or instructions in these sections may also need to be distributed to different persons within that department.

• Follow the steps indicated by the guide in interpreting the results and/or implementing the organizational changes indicated.

• The CEO and other high ranking administrators should demonstrate full support in the creation of any organizational changes recommended by the director and the committee or council.

• Some steps and checklists should be repeated after the implementation of changes as a means of measuring success.

• This initiative should be viewed as a long-term, on-going commitment to developing and maintaining cultural and linguistic competence.


Further Reading:

Brach C, Fraser C: Reducing Disparities through Culturally Competent Health Care: An Analysis of the Business Case. Quality Management in Health Care 2002; 10(4):15-28.

Kairys JA, et al: Assessing Diversity and Quality in Primary Care Through the Multimethod Process (MAP). Quality Management in Health Care 2002; 10(4):1-14.


Appendix I: CLAS Standards*

1. Health care organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

2. Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.

3. Health care organizations ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

4. Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

10. Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

11. Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

12. Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

13. Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.

14. Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.

15. Health care organizations should ensure that data on the individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.

16. Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

17. Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms, to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.


18. Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.

19. Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS Standards and to provide public notice in their communities about the availability of this information.

*Office of Minority Health, U.S. Department of Health and Human Services. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Rockville: IQ Solutions, 2001.


Appendix II The Culture, Language and Health Care Connection**

Avoiding Stereotypes: The information presented below offers examples of some of the health beliefs and behaviors that have been attributed to members of several diverse cultural groups living in the United States. It should never be assumed that membership in a particular cultural group means that any individual either ascribes to any or all of the belief or behaviors described below. The information provided here is intended to add an additional perspective to the understanding of individuals who may be exhibiting behavior which seems strange or unfamiliar. Each patient must be assessed as a unique individual, not as a member of a particular group. The degree to which an individual adheres to the traditional belief system or the behaviors attributed to a particular cultural group depends upon many factors. These include the number of years the person has lived in the United States, the environment in which he or she lives, and the person's level of education and socioeconomic status. Health care institutions and caregivers are cautioned to avoid stereotyping individuals based upon the broad cultural norms described below. This information merely provides a few examples of the many ways in which culture may impact health beliefs, the way a patient may respond to pain, and the different forms of treatment. It should not be taken to imply that all members of a particular group hold to the behavior or beliefs presented. When a patient or a patient's family responds in ways that medical staff find confusing, it is recommended that questions be asked to assess for their adherence to traditional beliefs.

Questions to further assist in cultural assessment can be found in the following articles:

Kleinman, Eisenberg & Good article, "Illness and Care, Clinical Lessons from Anthropology and Cross Cultural Research, Ann. Int. Med., 1978, Feb., 88(2),251-8.

Spector, R. E. Cultural Diversity in Health and Illness (attachment), 6th Edition, Prentice Hall, 2003, Lieberman, et. al. "Woman's Health Care: Cross-Cultural Encounters Within the Medical System" Journal of the Florida Medical Association, August/September, 1997,Vol..81,#1.

Warren B, Capinha-Bacote, J., Munoz C, in Munoz C. Cultural concepts to consider in the care of the ethnically diverse client and family, Ohio Nurses Review 2001.

Salimbene, S., What Language Does Your Patient Hurt In? A Practical Guide to Culturally Competent Patient Care, 2nd Edition, Diversity Resources, to be published Fall, 2004.

Interpersonal Commentary On the purely interpersonal level, for example, members of the U.S. culture, generally admire "equality" and "informality." Many members of this dominant caregiver population demonstrate caring and compassion by smiling at the patient, patting the patient on the arm, shoulder, or head, and/or addressing the patient by his/her first name. This behavior can be interpreted by members of cultures who use a formal, impersonal


version of the pronoun "you" with anyone who is not a close friend or relative or who address one another in terms of role (e.g. brother, sister, oldest daughter, or aunt) as being impolite and disrespectful. In cultures that believe that a person's soul resides in the head, it can be considered intrusive or even a cause of illness to touch someone on the head without permission. In other cultures, it is impolite to smile at someone one does not know, especially if that person is of a higher status such as a physician or nurse! In the same manner, the behaviors of caregivers who belong to a rather formal culture – or one that is referred to as a "distance" or "non-touch" culture may also be misinterpreted by patients who come from a more informal, "touch" culture such as our mainstream White culture in the U.S. The patient may fail to develop a sense of trust with a caregiver whom they have labeled as "unfeeling" or "unconcerned."

Expectations of Type and Extent of Medical Exam Culture also determines the patient's needs and expectations regarding the type and extent of the medical exam and treatment. For example, in traditional Chinese medicine, the physician examined the patient by taking the pulse at seven different pressure points and looking at the tongue in several different places. Traditional Chinese physicians rarely resort to an invasive examination or treatment of any kind. Often illness is attributed to an imbalance of Yin and Yang. Balance is restored by foods or medications of the lesser force. Most traditional medications are taken orally as a liquid or slush. On the other hand, some Latino patients may prefer medications to be given in hypodermic form. In Mexico, medication is often given in hypodermic form and the caregiver always "gives/prescribes something" – even if it is a placebo or a suggestion for a minor change in lifestyle. Failure to give any medication or advice may cause the patient to go away with the feeling that he/she received inferior treatment. Latino patients who follow traditional rules of etiquette expect the caregiver to offer his/her hand in greeting at every office visit. They may also wish to place themselves in the "expert hands" of the physician and not want to share in the decision-making process regarding treatment options. If the physician asks the patient to participate in the choice of treatment plan, the patient may lose confidence in the physician's medical experience and expertise.

Expression of Pain Research has shown that though the sensation of pain is similar for most populations, there are major cultural differences in the manner in which pain is expressed. Members of some Asian groups, for example, may not exhibit pain behavior and may refuse medication, while members of other groups may cry out when pain should be relatively slight as a means of demonstrating their "delicacy." Although in Mexican culture, loss of self-control is frowned upon, and men are expected to resist outward expression of pain, caregivers in the United States often label Mexican females patients as "crybabies" because they frequently cry-out a great deal during labor. What these caregivers don't understand is that this behavior does not indicate lack of control, and that the "message" intended by the cries is not, "I expect you to do something!" but "I am sharing the pain with you so that I feel it less intensely." In other words, the cultures of different population groups may dictate very different pain behavior so it is important for caregivers to refrain from making assumptions about the meaning of these behaviors based upon the behavioral dictates of their own culture. They should also refrain from


making a generalization about a patient's pain behavior which is based upon the patient's cultural group.

Surgery There is little surgical tradition in much of Asia. Confucius is believed to have said that the body is only "loaned" to the person while he/she is on earth. Only those who return the body "whole" are allowed to go to heaven. This belief may cause an Asian patient to refuse to consent to surgery that requires the removal of a tissue or body part.

Alternative Medicine Patients from many cultures may use alternative therapies – either instead of or concurrent with Western treatment. Often these treatments will not harm the patient, but it is important for caregivers to encourage patients to disclose these treatments because some may be harmful, either by themselves or in conjunction with what the physician prescribes. Some traditional treatments are misinterpreted by caregivers. Two popular pan-Asian treatments are "coining” and “cupping.” In "coining," a coin or other piece of metal is heated and rubbed on the infected area until red welts appear. In cupping, glass cups are heated until the air is removed and, then, placed on the back or chest. The removal of the cup causes red welts to appear on the skin. Often when these marks are found on women or children, caregivers, not trained to recognize this cultural practice, suspect and report spousal or child abuse.

Culture, Colors and Decor Culture also molds patient and caregiver perceptions about what the waiting room or clinic should look like and even where certain departments should be located. How would an individual feel, if either labor and delivery or surgery were on the fourth floor, and that person, as do many Asians, associate the number four with death? White has always been the "preferred color" of hospital corridors, waiting rooms, and physician coats. Why? This is because to members of Western European culture, white symbolizes cleanliness, purity, and peacefulness. To many Asian groups, however, white is a color that is reserved for death and funerals!

Culture and the Institution's Bottom Line As one can see, culture, looked at from these different perspectives, can seriously impact a medical institution's bottom line! It may ultimately determine whether or not members of a particular population group initially choose that healthcare organization as a healthcare provider, are satisfied with their treatment results, and remain loyal patients/clients of that organization. Competency in treating culturally diverse patients will enable an institution to retain a larger service population. When caregivers understand the needs, beliefs and concerns of various cultures in their service area, they can modify care and treatment to make it more appropriate to the particular patient’s lifestyle and belief system. Care that does not conflict with a patient's cultural beliefs improves compliance with the taking of medication and recommended lifestyle changes. Patients, too, tend to be more forthcoming in disclosing alternative treatments if they feel that the caregiver will respect, not ridicule, these methods. As a result of greater trust, openness and compliance, the frequency and extent of bad outcomes can be minimized.


Furthermore, legal suits that are the direct or indirect result of bad outcomes caused by miscommunication and mistrust between caregiver and patient can be measurably reduced.

References & Further Reading

Calvillo, E.R., Flaskerud, J.H., "Evaluation of the pain response by Mexican American and Anglo American women and their nurses, "Journal of Advanced Nursing, 1993, 18, 451-459

Galanti, Geri-Ann, Caring for Patientf from Different Cultures, 3rd Edition, 2004, Philadelphia, University of Pennsylvania Press

Helman, C.B., Culture, Health & Illness, 4th Edition, Boston, Butterworth Heinemann

Lipson, J.G., Dribble, S.L., Minarik, P.A., eds. Culture and Nursing Care: A Pocket Guide, San Francisco, UCSF Nursing Press, 1996

Ng, B., Dimsdale, J., Shragg, P, Deutsch, R, "Ethnic Differences in Analgesic Consumption for Post Operative Pain," Psychosomatic Medicine 58: 125-129 (1996) Suzanne Salimbene, Ph.D. “Methods for Improving Cultural Competence,” (203-222) Burns & Northrup, eds., Guide to Managed Care Strategies, 1999, Faulkner & Gray New York

Salimbene,S. What Language Does Your Patient Hurt In? A Practical Guide to Culturally Competent Patient Care, Amherst, Diversity Resources, 2000

Weber, S.E., Cultural Aspects of Pain in Childbearing Women, JOGNN, 25(1),1996, 67-72


Section #2, Guide to Conducting and Interpreting the Institutional

Audit

General Directions Do not burden one person with the completion of all of the checklists in this section. Although one person should be responsible for the distribution and collection of the information, the forms should be distributed to the person or department most likely to have the information at hand or most likely to be impacted by the results. Remember, this is an institutional self-audit. The information will remain within the organization. It has been developed to assist each individual institution to clarify where it stands on a continuum of cultural competence and what areas of cultural and linguistic competence require the most attention. The more thoroughly the checklists are completed, the greater will be its usefulness in helping the institution plan a more successful implementation of CLAS Standards. (Note: The Census figures will be available for each institution's service area. If the institution does not yet gather official data on its patients’ race and ethnicity, estimate the patient demographics. In the future, race and ethnicity might be included on intake forms because this information will provide valuable data about current and future service populations).

What can be learned from Checklists #1 and #2?

1. Changes in patient demographics (or estimated patient demographics) a. Compare 1990 or earliest record of patient demographics with the most recent

demographics j. Compute increases and decreases in patients from ethnic groups k. Determine whether there are new groups moving into the service area l. Use the U.S. Census Bureau predictive figures for 2010 to forecast changes in

current patient populations

2. An estimate of how much each population group believes in the institution's ability to serve them effectively a. Compare the 2000 Census figures (per race and ethnic group) with the patient

figures (or estimated patient figures) at the institution j. Determine the percentage of the population group that has opted to use the

institution k. If only a small percentage of the population of any ethnic group in the service

area is utilizing the facility, it is possible that the facility does not hold the confidence of that community. To investigate the cause of this lack of confidence, select a person or committee to check the attitudes of the population group toward the institution. This can be done by contacting community leaders and organizations and conducting an informal survey of that group's attitudes about the quality of care provided by the institution.

3. A comparison of patient demographics with staff demographics CLAS Standard #2 recommends that healthcare organizations work toward developing a balance between staff demographics throughout the organization and


the demographics of the populations that they serve. The replies of Checklists #1 and #2 will allow a comparison of the staff and patient demographic data. While at this time it may not be possible to have an equal balance between the ethnic/racial/cultural backgrounds of patients and staff throughout the country, it is important that the culturally competent organization makes a good faith effort to accomplish this balance within the next decade.

What can be learned from Checklist #3? This is a checklist that should be filled out by one or more of the top decision-makers. Their answers will help leadership identify the extent of their commitment to the cultural competence initiative. (Note: Should the organization's leadership not be in full support of implementing CLAS, they may wish to postpone this journey. The experience of other organizations has shown that full support of top leadership is necessary for a successful implementation of CLAS. Anything less than full support often results in failure, needless expense, and an unhappy and frustrated lower chain of command and staff).

What can be learned from Checklists #4 and #5? Checklist #4 will illustrate how easily the institution has made it for culturally diverse patients/consumers to access health services. Checklist #5 will indicate whether or not the institution has incorporated community leadership as a source of information as well as a source to help improve access to care. These checklists will suggest ways in which community leaders might be utilized to build support and improve patient/consumer satisfaction.

What can be learned from Checklist #6? This checklist will indicate how well the institution currently measures up to the CLAS Standards. The answers will help the institution to identify the strongest and weakest points of cultural competency and decide which issues should be dealt with first.


Section #2, Checklist #1: Present and Future Patient Demographics

Ethnicity of Patients in Service Area

1990 or Earliest Patient

Demographics*

2000 or Most Recent Patient Demographics*

Increase/ Decrease of

Ethnic Patient Group

2000 U.S. Census

Figures for Areas Served**

2010 U.S. Census Forecast Figures

for Areas Served**

Expected Increase/Decrease of Ethnic Groups

Served Total White (Non-Hispanic) List ancestry of most recent immigrants below (e.g. Polish, Bosnian, Russian)

Number/Percent Number/Percent Number/Percent Number/Percen t

Number/Percent Number/Percent

Total Hispanic List ancestry below (e.g. Mexican, Haitian, Cuban)

Black (Non-Hispanic)

American Indian

Total Asian/Pacific Islander List ancestry below (e.g.

Chinese, Japanese, Hmong)

Asian Indian

Muslim (e.g. Middle Eastern, Pakistani, Others)

Total patients seen

*If records of patients’ race and ethnicity have not been kept, estimate these demographics. **See U.S. Census Race/Ethnicity by Community © Suzanne Salimbene, Inter-Face Intl. 2001- All Rights Reserved 13

Section #2, Checklist #2: Present Staff Demographics

Ethnicity of Staff in Institution

Administrators (Managers,

Supervisors)

Physicians (MDs, DOs)

Nurses (RNs, NPs, PAs,

Techs, etc.)

Clerical Staff Misc. Staff (Housecleaning,

Food)

Total Staff Members

2000 or Most Recent Patient Demographics*

Total White (Non-Hispanic) *List ancestry of most recent immigrants below (e.g. Polish, Bosnian, Russian)

Number/Percent Number/Percent Number/Percent Number/Perce nt

Number/Percent Number/Percent Number/Percent

Total Hispanic *List ancestry below (e.g. Mexican, Haitian, Cuban)

Black (Non-Hispanic)

American Indian

Total Asian/Pacific Islander *List ancestry below (e.g. Chinese, Japanese, Hmong)

Asian Indian

Muslim (e.g. Middle Eastern, Pakistani, Others) Total of all ethnicities

*This information is found in Section #2, Checklist #1. Either use the 2000 or most recent Patient Demographics or, if these are unavailable, use the 2000 U.S. Census figures for the area served. This column is present to help in the comparison of Checklists #1 and #2.


Analysis of Section #2, Checklist #2

10. How well do the staff demographics match the demographics of the patients served (or estimated demographics)?

Excellent _____ Well _____ Some Improvement Needed _____ Not Well _____

11. At what levels of the staff hierarchy are the majority of the minority employees? (Note: If the organization finds that minority workers are primarily at the lower levels of employment, the Human Resources Department will need to make a strong effort to increase the cultural diversity of the upper level staff.)

Administrators ______ Physicians _____ Nurses _____ Clerical staff _____

Food/Maintenance ____

12. Identify conflicts which have resulted from the mixture and/or non-mixture of culturally diverse employees and patients.

a. List problems that have occurred between staff members who belong to different cultures that impact:

Teamwork ________________________________________________________

Communication ___________________________________________________

Other (______________) ____________________________________________

b. List problems that have occurred between staff members and patients who belong to different cultures that impact:

Communication ___________________________________________________

Trust ____________________________________________________________

Correct Diagnosis __________________________________________________

c. Review the above list when the organization begins to plan training in cultural and linguistic competence. Make sure that the issues behind these difficulties are addressed in training.

4. Increasing staff diversity and cultural competence

a. A specific strategy to recruit culturally and linguistically diverse administrative, clinical and support staff is being utilized. Yes No


_______________________________________________________________

_______________________________________________________________

j. The retention statistics for these employees are: ____________________

k. The promotion statistics for these employees are: ___________________

l. Analyze the promotion and retention statistics.

10) Which group(s) seems to have a lack of retention?

11) Which group(s) seems to have a lack of advance?

m. The institution actively seeks to recruit employees who have received cultural competency training and who have demonstrated cultural as well as job competence. Yes No

n. Consider how the organization might build efforts to develop cultural competence into promotion and advancement.


Section #2, Checklist #3: Assessment by Leadership

This checklist is intended to assist top leadership assess their personal commitment to cultural competence. It need not be shared with anyone else in the organization. Experience has shown that a strong positive commitment is necessary for the implementation of CLAS to succeed. This implementation should probably not be started until it becomes a top priority for the highest levels of leadership.

1. I view building a culturally competent organization as a:

____Top Priority ____Priority ____Lesser Priority ____Good, if not costly

10. List at least three specific measures that I, as leader of the organization, have already taken to “walk the talk” or to demonstrate to my management, staff, and the community, my commitment to offering culturally and linguistically appropriate services to diverse patient groups.

a.__________________________________________________________________

b.__________________________________________________________________

c.___________________________________________________________________

11. Is there a specific person or department assigned to promoting diversity or cultural competence? Yes No (If you answered No, proceed to #7. If you answered Yes, continue with #4.)

12. What is the title of that person or department? _______________________________

13. Does that person or department report directly to me? Yes No

14. Has that person or department been given broad decision-making power? Yes No

10. In the first column below, list all specific vehicles, which the organization has already implemented to promote items a and b; in the second column list the key element(s) (e.g. training, interpreters, signage or additional staff) of these vehicles. In the third column, indicate S for single intervention, R for repeated on a regular basis, or O-G for on-going interventions.

a. Teamwork among staff of different cultures:

1) _____________________________________ _________________ ____

2) _____________________________________ _________________ ____

3) _____________________________________ _________________ ____


b. Cultural and linguistic competency in serving culturally diverse patients:

1) _____________________________________ _________________ ____

2) _____________________________________ _________________ ____

3) _____________________________________ _________________ ____

11. List at least 3 other measures which I would like our institution to take this fiscal year to promote cultural and linguistic competence.

j. __________________________________________________________________

k. __________________________________________________________________

l. __________________________________________________________________


____________________________________________________________________ ____________________________________________________________________

____________________________________________________________________

Section #2, Checklist #4: Evaluation of Current Actions to Enhance

Cultural & Linguistic Competence

This checklist is an internal assessment of current practices. It may be helpful to ask or consult with the training department and/or the human resources department to complete this section of the audit.

1. Organizational Mission Statement:

a. Staff diversity is mentioned in the mission statement. Yes No

b. Culturally and linguistically appropriate care is part of the mission statement. Yes No

2. Internal Organizational Communications

j. The need to offer culturally and linguistically appropriate services to diverse populations is frequently mentioned in internal memos, publications and internal computer notices. Yes No 10) Indicate the number of times this has been mentioned in communications

during the past month. _____ 2) Indicate the number of times this has been mentioned in communications

during the past 6 months. ______

b. The need for cultural awareness and sensitivity to colleagues of different races, ethnicities and cultures is a frequent topic of internal memos, publications and postings on the internet. Yes No 10) Indicate the number of times this has been mentioned in communications

during the past month. _____ 11) Indicate the number of times this has been mentioned in communications

during the past 6 months. ______

3. Cultural Diversity Education

j. An internal course on the cultural beliefs of the specific patient populations is required of all staff. Yes No (If answered No, proceed to #3f. If answered Yes, continue with #3c.)

k. The departments/individuals required to take the course are:


1) ___________________ 2) __________________ 3) _________________

4) ___________________ 5) __________________ 6) _________________

c. List the topics covered by the course (e.g. religious/cultural beliefs, proper etiquette such as forms of address and "rules of touching," specific health/illness beliefs and practices and the appropriate treatment modification for a particular patient group).

1) ___________________ 2) __________________ 3) _________________

4) ___________________ 5) __________________ 6) _________________

j. Indicate the length of the course in hours. ______

e. Indicate how many times the course is offered per year. ______

f. Specific teambuilding provisions to improve the communication and teamwork between employees of different cultural, language and ethnic groups are provided Yes No

13. Community Involvement The organization regularly works and/or consults with many of the community’s cultural, ethnic and religious groups regarding the forms of care and services which should be made available to their members. Yes No

14. Other Measures List all other measures below which the organization has already taken as a means of ensuring a culturally and linguistically competent work environment (i.e. Human resources has been instructed to increase the diversity of staff at all levels or cultural competence is used as an indicator of career advancement).

a. ___________________________________________________________________

b. ___________________________________________________________________

c. ___________________________________________________________________

15. Overall Rating Rate the organization’s overall status in cultural competence at this time.

Fully competent ___ Excellent ___ Moderate ___ Needs much improvement ___


Section #2, Checklist #5: Patient/Community Access to Culturally and Linguistically Appropriate Care

This checklist is an internal staff assessment and may be directed to the person(s) responsible for customer care or community relations. This person might be given the responsibility of gathering information from employees in the various departments and objectively determining the effectiveness of these services. It is also possible for individual departments to analyze and evaluate the first three sections listed below.

1. Telephone Services

. List the provisions currently available to assist non-English speaking callers in the first column and the language(s) for which these services are available in the

second column.

1) ______________________________ _______________________________

2) ______________________________ _______________________________

3) ______________________________ _______________________________

b. List the type of training/instructions that telephone operators receive to help them appropriately handle calls from non or limited English speaking persons.

1) ________________________________________________________________

2) ________________________________________________________________

3) ________________________________________________________________

2. Patient care

a. Rate the knowledge and open-mindedness of staff physicians and nurses regarding possible health/illness beliefs and practices of the specific patient groups that they may be called upon to treat.

1) Physicians: Excellent ___ Above Average ___ Average ___ Poor ___

2) Nurses: Excellent ___ Above Average ___ Average ___ Poor ___

b. Medical caregivers have been given written guidelines regarding working with patients from other religions, cultures or language backgrounds. Yes No

10) These guidelines are distributed via: __________________________________

11) Something is being done to enforce these guidelines. Yes No


c. Caregivers have been taught specific strategies for taking an accurate history and physical on culturally and linguistically diverse patients. Yes No

These strategies are followed on a consistent basis. Yes No

m. Staff have easy access to medical, pharmacological and epidemiological information about specific patient groups. Yes No

1) Cultural and/or religious information is also available. Yes No

2) This information is made available through: ___________________________

n. Staff have been given lists of possible alternative medications or other measures which might be used by specific patient groups. Yes No

o. Staff have been given lists of community leaders who might be helpful in assisting with patients from each culture. Yes No

p. Staff are aware of the types of medications, procedures, and/or medical approaches which might be forbidden by cultural and/or religious laws. Yes No This awareness is verified via: _________________________________________

q. Caregivers know the dietary and eating habits of patient groups and take these into account when giving patients a special diet or advice concerning food to favor or to avoid. Yes No This information is provided via: _______________________________________

3. Physical Environment

a. What are the colors of the walls? _______________________________________

b. Studies have been conducted regarding the specific numbers, colors, etc. to use or avoid when working with the specific cultural groups regularly served by our institution. Yes No

l. The pictures, decorations, etc. are meaningful and/or soothing to members of other cultures. Yes No

m. In the waiting areas, culturally appropriate refreshments, reading materials, etc. are available. Yes No

n. Appropriate areas for prayer, contemplation and/or family discussion regarding medical decisions are available to patients and their families. Yes No


f. Admissions desk staff, office personnel and triage persons trained to identify and deal with cultural, religious and language differences. Yes No

10. Emergency room/Walk-in and Appointment Services

a. Assess language access for the patient populations served. Indicate whether or not forms, signs, patient education materials, and customer satisfaction surveys are offered in the native language of each population group.

k. Assess interpreter access for the patient populations served. Indicate whether or not a full-time, on-site interpreter or some other form of interpreting service (e.g. phone company operator) is utilized for each population group.

Patient Population

Groups in the Service Area

Forms (e.g. in-take, billing and

consent)

Signs Patient Education Materials

On-site Interpreters

Other Interpreters (e.g. phone company)

l. The following statements refer to the quality of the on-site interpreters:

1) They are easily accessible to the patients. Yes No

2) The majority are professional medical interpreters. Yes No

10) The majority are volunteer interpreters. Yes No

4) The volunteer interpreters are knowledgeable in medical terminology. Yes No

5) The volunteer interpreters receive an orientation/training in medical interpreting. Yes No

10) The volunteer interpreters receive compensation (e.g. extra vacation time, yearly bonuses and/or awards) for performing these services. Yes No


_______________________________________________________________

_______________________________________________________________

5. Other services

a. Food

1) Meals are planned around the eating habits and dietary laws of the major patient groups. Yes No

2) Family members are permitted to bring certain selected foods to the patient. Yes No

b. Visitation

1) Visiting regulations are flexible enough to accommodate the customs of different patient groups. Yes No

2) List the visiting hours. ____________________________________________

12) List the maximum number of visitors allowed at one time. _________

4) Define the term “close family members” as it pertains to visitation regulations.


Section #2, Checklist #6: Community Involvement, Input and Support (CLAS Standard #12)

1. Community Involvement in Improving Accessibility of Care

a. Indicate whether or not community feedback has been sought on the language and interpreter services that the institution provides for each patient population.

b. Indicate whether or not customer satisfaction surveys are provided in the native language of each patient population.

Patient Population

Groups in the Service Area

Community Feedback on

Forms (e.g. in-take, billing and

consent)


Signs


Patient Education Materials


On-site Interpreters


Other Interpreters (e.g. phone company)

Customer Satisfaction

Surveys


2. Utilization of Community Organizations for Input and Support

a. List the important community and/or religious organizations affiliated with each patient population in the service area.

b. Indicate the institution's ability to incorporate feedback from important community and/or religious organizations in the development of a culturally diverse environment.

Patient Population Groups in the Service

Area

Important community and/or religious organizations

Direct Contact is established between the healthcare

organization and the community

organization

A member of the community

organization serves on one of the institution's

advisory boards and/or committees

Input on how to improve patient satisfaction has been requested

from the community

organization


_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

3. List other forms of community group involvement and/or support that the

institution is currently engaged in or desires to implement in the future.


Further Reading

Frusti DK, Niesen KM & Campion JK: Creating a culturally competent organization: use of the diversity competency model. Journal of Nursing Administration 2003; 33(1):31-8.

Siegel C, Davis-Chambers E, Haugland G, Bank R, Aponte C & McCombs H: Performance Measures of Cultural Competency in Mental Health Organizations. Administrative Policy of Mental Health 2000; 28(2):91-106.


Section #3, Guide to Devising a Workable Strategic Plan (CLAS Standard #8)

This section guides the institution in the creation and implementation of a written strategic plan for initiating and fostering cultural and linguistic competency throughout the organization. The plan helps each organization define its particular long-term and short-term goals and develop specific plans to achieve them. The strategic plan is intended to cover a 5-year period. It suggests some mechanisms for measuring success and reporting upon progress on a yearly basis. It also guides institutions in re-defining and extending goals once the 5-year period has been completed.


Section #3, Checklist #1: Setting and articulating cultural competence goals to fit into the organizational mission statement, operating

principles, and service focus

1. Mission Statement Often the organizational mission statement was formulated prior to demographic changes, which have and will continue to result in increases in diversity of staff and patients. It is recognized that mission statements cannot be re-written each time an institution begins a new initiative. However, cultural and linguistic appropriateness have now become inseparable from quality care, as well as customer and staff satisfaction and retention. While this portion of the guide may not immediately lead to a revision of the mission statement, it will help those involved in the institutional decision-making process to access the impact of cultural and linguistic competence on achieving the mission as it stands today. This exercise may also assist the primary decision-makers in the present and future revisions of individual mission statements.

a. Write the organizational mission statement in the left column below, placing each sentence on a separate line.

b. Analyze each point or sentence. List the ways that this aspect of the mission may impact the access to or quality of care or services provided for culturally or linguistically diverse patients in the blank spaces below each point in the left column.

c. Rewrite or revise each point or sentence in the right column to specifically indicate the organization’s commitment to offering that quality of service to culturally diverse populations.

Mission Statement & Analysis Revisions of Mission Statement

1. _________________________________

___________________________________

___________________________________

2. _________________________________

___________________________________

___________________________________

3. _________________________________

___________________________________

___________________________________

4. _________________________________

___________________________________

___________________________________

1. _________________________________

___________________________________

___________________________________

2. _________________________________

___________________________________

___________________________________

3. _________________________________

___________________________________

___________________________________

4. _________________________________

___________________________________

___________________________________


__________________________________________________________________

__________________________________________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

d. Consolidate the revised points into a comprehensive mission statement which indicates a strong commitment to providing culturally competent employment, patient and staff services, and medical care. ____________________

e. Submit the analysis and the revised mission statement to the governing board of the institution with a request that they be considered in future examinations of the mission statement.

2. Operating principles a. Write the organization's operating service principles in the left column below,

placing each point or sentence on a separate line. b. Analyze each point or sentence. List the ways that this aspect of the operating

principles may impact the access to or quality of care or services provided for culturally or linguistically diverse patients in the blank spaces below each point in the left column.

c. Examine the operating principles which may inhibit the institution’s ability or efforts to provide culturally and linguistically appropriate services to culturally diverse populations or offer less than excellent working or advancement opportunities to culturally and linguistically diverse employees.

m. Revise these principles in the right column to support, rather than inhibit, excellence in management of clients and staff.

n. Discuss the procedures that are necessary to implement these modifications.

Operating Principles & Analysis Revisions of Operating Principles

1. ____________________________________

2. ____________________________________

3. ____________________________________

4. ____________________________________

1. ____________________________________

2. ____________________________________

3. ____________________________________

4. ____________________________________


3. Service Focus

a. Analyze the focus of the services offered by the institution.

b. Compare these to the services mandated or suggested by the CLAS Standards.

c. Use the appropriate section of the institutional audit to determine whether the institution's service focus adequately meets the needs of: 1) The current population in the service area 2) The present client/patient population 3) Estimates of the population in the desired service area for 2025

d. Make a list of any services which may become obsolete by 2025.

e. Make a list of any new services which might be needed between now and 2025.

f. Discuss how the institution might begin to modify its focus so that it meets both the CLAS Standards and the expectations of the populations who will be served in the next 20+ years.


Section #3, Checklist #2: Developing a 5-Year Plan

The implementation of CLAS and the creation of a culturally and linguistically competent health care organization and staff involves an on-going and permanent commitment on the part of the entire organization. Even the initial work involved in meeting the CLAS standards and evolving as a culturally competent health care institution may require 5 years to fully implement. Below are suggestions for creating a workable 5-year plan. The goals and plans set for each 5-year period may be further divided into yearly and, then, into quarterly implementation periods to make it easier to track accomplishments and identify parts of the plan which may need revision. However, please note that both service populations and staff demographics change with time, making it essential to continue to train old and new staff members. Thus, after implementation of this initial 5-year plan, organizations will need to develop another 5-year plan to determine and track continuing projects.

1. Analyze the findings of the Institutional Audit (Review all 6 checklists)

a. Make a list of everything that the institution must do to consider itself a Culturally and Linguistically Competent organization and to be fully in compliance with the 14 CLAS Standards.

b. Link connected areas (i.e. increasing the diversity of staff at all levels, increasing educational opportunity or becoming an organization which is tolerant of differences).

c. In the table below, place the more important problem areas and their connected components in the To Do column. Record the staff member or department in charge of implementing the task in the By Whom column. Develop a planning timeline for the completion of each step and note the date in the When column. In the Other Considerations column, the following issues may be considered:

1) Identify those To Do actions that are believed to require a substantial budget and those which can be accomplished without much cost to the organization.

2) Identify those actions for which the organization already has the infrastructure and those for which an infrastructure must be created.

3) Identify those actions which only require a one-time intervention and those which require multiple or on-going interventions

4) Identify those actions which seem easy to implement and those which seem difficult to implement.


To Do

By Whom When Other

Considerations

2. Divide the tasks outlined above into a 5-year implementation plan, using the following criteria:

a. No person or department is burdened with more than one major task or four minor tasks per year

m. Monetary outlay is divided equitably over a 5-year period. (Note: Expenditures for on-going staff training throughout the organization may be greatest during the first year, but a major effort should be made to train some members of each segment of the staff population each subsequent year.) 1) The creation of any new infrastructure is spread out over the 5 year period. 2) One time and on-going interventions are combined each year.

3. Review and revise this 5-year plan at the close of each year. Determine what goals (i.e. items listed on the "to do list" above) have or have not been met, which costs have been under or over-estimated and how to best and most cost effectively meet the goals set by the Strategic Plan in the future.


Section #3, Checklist #3: Developing an accountability hierarchy for CLAS and cultural competence leadership throughout the organization

The achievement of cultural and linguistic competence requires an organization-wide effort. Leadership must set the tone, but every employee must be helped to understand the importance of cooperating with and contributing to these efforts. The manner of gaining the support of the organization as a whole will be discussed in detail in other sections of this guide. Some of the key elements needed for the successful implementation of CLAS are listed below:

1. A senior diversity/cultural competency leader (e.g. a Director of Diversity) who is responsible for coordinating these efforts throughout the organization is clearly delineated. This leader's effectiveness is greatly enhanced if he or she reports directly to the CEO and has decision-making power and a budget for building cultural and linguistic competence.

2. The department heads and managers throughout the organization share the responsibility for creating a culturally competent organization and culturally competent staff.

3. The diversity leader guides each department and division to devise short-term goal(s) for each quarter of the year. These goals will reflect areas of need as demonstrated by the findings of the institutional audit. Care must be taken to ensure that each goal can be practically accomplished within each department's budgetary and staff-availability framework.

10. Short reports on the accomplishment of each goal are required. The simple format illustrated below is suggested to make the process more time efficient.

Department: Quarter (Period):

Goal Description:

Accomplishment Deadline:

Status: �Complete � Item(s) still to be done

Details, requests for assistance, etc. (optional):

j. The Diversity Leader compiles this departmental information for use in a yearly report to the CEO.


k. A yearly report of accomplishments in the area of cultural and linguistic competence

is distributed to the entire staff and to the community that the organization serves.


Section #4, Guide to insuring that patients/consumers receive effective, understandable and respectful care provided in a manner that is

compatible with their cultural health beliefs and preferred language (CLAS Standard #1)

“This standard constitutes the fundamental requirement on which all activities specified in the other CLAS Standards are based,”1. Because this standard can best be implemented through the implementation of the other 13 Standards, this section of the guide will merely further define the concepts behind the Standard and offer suggestions for evaluating and improving services so that the other 13 Standards are easier to implement. The intent of this Standard "is to ensure that all patients/consumers receiving health care services experience culturally and linguistically competent encounters with an organization's staff."2 The following definitions of effective, understandable, and respectful care included in the Final Report3 are summarized below so that they may be easily referred to in the completion of this section of the guide.

"Effective health care is care that successfully restores the patient/consumer to the desired health status and takes steps to protect future health by incorporating health promotion, disease prevention and wellness interventions. In order for health services to have a chance of being effective in a patient, the clinician must accurately diagnose the illness, discern the correct treatment for that individual, and negotiate the treatment regimen successfully with the patient."

Culture plays an important role in the provision of effective care and services. The key to implementation of the statement above is the word: negotiate. It is not merely enough that the medical diagnosis be made correctly and that a medically correct treatment plan devised. If the treatment plan contains recommendations which are either taboo in the patient's religion or culture or if it cannot be made a part of the patient's lifestyle, it may prove ineffective with that patient. Culturally and linguistically appropriate care requires caregiver's to negotiate with the patient regarding the need for a particular treatment plan and work with that patient to make it a part of the patient's conceptual and life frame.

Understandable care focuses on the need for patients/consumers to fully comprehend questions, instructions, and explanations from clinical, administrative and other staff….[It] encompasses not only addressing language differences and ensuring linguistic comprehension but also explaining technical or specialized terminology and concepts and verifying that the patient/consumer understands the content of what is being said. "

For care to be truly "understandable" the concepts as well as the words used orally or in writing must "make sense" in the world view or cultural framework of patient/consumer. Culture gives conceptual meaning to words by shaping how those words are understood..

1 National Standards for Culturally and Linguistically Appropriate Services in Health Care, Final Report,

March 2001, Washington DC, p. 49

2 Ibid.

3 National Standards for Culturally and Linguistically Appropriate Services in Health Care, Final Report,

March 2001, Washington DC, p. 51


For example, should the culture of the patient not include in its world view, joint physician/patient responsibility for decision making, merely asking the patient, in his or her primary language, to participate in decision-making may not constitute "understandable care". The patient may understand the "words" of a phrase such as "You have three treatment options, X, Y and Z, which option do you prefer?" when these words are translated into the patient's native language. However the "custom" of patient sharing in decision-making may not be understandable. Culture may cause the patient to interpret the meaning of this utterance as "I am the physician but I do not know what to do."

Respectful care includes taking into consideration the values, preferences, and expressed needs of the patient/consumer and helps to create an environment in which patients/consumers from diverse backgrounds feel comfortable discussing their specific needs with any member of an organizational staff.

Each culture has its own ways of showing respect. Often U.S. caregivers address patients by their first names, because U.S. culture utilizes this informal form of address to indicate friendliness and caring and respectful "equality" to the person addressed. However, to a person from another culture, using the first name may be understood as a demonstration of disrespect by indicating that the speaker views the person as having a lower status. Thus, this first standard recommends that all care to be provided in a manner that is not only linguistically and a culturally appropriate, but in a way that will be interpreted as respectful by the patient/consumer.

Note: The information which was gathered in completing Section #2, Checklists #1 and #5 can serve as a resource in the completion of this section of the guide.


Section #4, Checklist #1: Improving the "Effectiveness" of Care

1. Outcomes Statistics Gather and compare outcomes statistics for each group with those of the general or majority population served. (Note: If the organization does not keep statistical records by race/ethnicity, it is highly recommended that it begin to do so. An important indication of an institution's overall cultural competency is statistical comparisons by race/ethnicity of outcomes, repeat presentations, and patient satisfaction. If these records are not kept by the organization, it may not be possible to trace those patients for whom an interpreter was used.) Answer the questions below as a means of assessing the effectiveness of the care currently being offered to each of the population groups served by the organization:

a. Is there statistically a greater number of unsuccessful outcomes (based on medical or negative customer satisfaction reports) in one population group in comparison with those of other population groups?

b. Is there statistically a greater number of patients in any or all of the above groups that do not complete treatment than there are with the majority population groups?

c. Is there a statistically greater number of repeat presentations of the same complaints?

2. Effectiveness of Care The answers to the above questions are measures of the effectiveness of care. A higher rate of poverty in many culturally diverse patient groups is often given as the major cause of unsuccessful treatment outcomes, failure to complete treatment, or to return with re-occurrences of the complaint. However, while poverty or low literacy may play a role, so may patient perceptions of the quality of care which they are receiving. These perceptions are strongly influenced by culture. It is recommended that institutions take a proactive role in lowering statistical differences in the above by taking steps to improve the effectiveness of care. The following steps are suggested:

a. Supply clinicians with current information regarding: 1) Susceptibility of particular ethnic/racial groups to certain diseases 2) Possible lifestyles and dietary habits which might impact health or make it

difficult for patients to follow treatment plans

b. Improve the ability of clinicians to communicate effectively with their patients directly or via interpreters through: 10) Training in communication skills (including how to effectively negotiate a

treatment plan which the patient will be able and willing to follow) 2) Training in cultural awareness, understanding and acceptance of beliefs and

lifestyles different from their own 3) Improved interpreter services (See Section #4, Checklist #2)


Section #4, Checklist #2: Improving the "Understandability" of care and services

1. Linguistic Comprehension Linguistic comprehension requires the availability of interpreters who know the language and dialect of the patient, understand medical terminology in both languages and also understand the impact of culture, educational level, and economic status upon the meaning attributed to questions and statements. The patient/client may understand the words the interpreter is saying, but may misconstrue the meaning behind the words unless cultural factors are taken into account. Under OCR Title VI, federally funded institution should take reasonable steps to provide LEP persons with professional medical interpreters and have them be available to assist these patients at any and all times the patients are seen. According to this ruling, every institution receiving federal funds should meet this criterion. Below is a suggested procedure to help satisfy this ruling quickly and cost effectively.

Start with the 3-5 language groups most frequently served by the institution. (The number will be dependent upon the size of the facility and the diversity of the service area). Institutions should actually employ professional staff interpreters for population groups for which they see 10 or more patients per day. All other language groups served by the institution must also be provided with interpreter services at no cost to the patient. However, these services might be provided through:

a. Prior arrangements for professional medical interpreters to be on call on an "as needed basis"

b. Bilingual staff who have indicated a desire to serve as interpreters and who have met the following criteria (Note: Some monetary or scheduling incentive should be offered to these personnel): 1) Certification through an oral and written test of their knowledge of

conversational and medical language in both English and the language of interpretation

11) Specific interpreter training (36-42 hours training)

c. A telephone service utilizing trained medical interpreters (Note: Arrangements for this service should be set up in advance of need.)

2. Conceptual Comprehension Technical and specialized terminology and concepts must be explained to patients/consumers in a manner that is appropriate to their world view, which is often culturally determined or influenced, and their educational level. It is important that caregivers and other staff verify patient/consumer understanding o

CLAS A-Z: A Practical Guide for Implementing the National ... · When the National Standards for...

Documents

Transcript of CLAS A-Z: A Practical Guide for Implementing the National ... · When the National Standards for...